30有毒化学蒸汽云泄漏.docxVIP

INVESTIGATION REPORT REPORT NO. 2004-09-I-GA APRIL 2006 TOXIC CHEMICAL VAPOR CLOUD RELEASE (154 Treated, Five Hospitalized for Toxic Chemical Exposure) 调查报告 编号：2004-09-I-GA 有毒化学蒸汽云泄漏 （因接触有毒化学品，154人接受治疗、5人住院） 1 Incident Description 1.1Process Upset A short time after loading the allyl alcohol, the operators noticed that the reactor temperature had increased from 32° F to about 72° F, presumably due to the addition of the warm allyl alcohol. Ten minutes later, the operators noted that the temperature had already climbed to 103° F. The temperature continued to increase rapidly to 118° F, well above the peak temperature of about100° F that they expected. Unknown to the engineers and operators, it was almost at the temperature at which the exothermic decomposition reaction occurs. Rapidly increasing pressure in the reactor caused the manway gasket to blow out (See Figure 1). Dense, white vapor immediately began to spray out of the manway. The rupture disc (Figure 2) blew open about 30 seconds later, sending additional white vapor out of the end of the 4-inch vent pipe near the base of the reactor. The last observed reactor temperature was 124°F. 1、突发事件 1.1工艺故障 向反应器加入烯丙醇后不久，操作员注意到反应器的温度从32°F升高至72°F，大概是由于加入了温的烯丙醇。十分钟后，操作员发现温度已经攀升到了103°F。温度持续升高至118°F，而预期的最高温度为100°F。118°F几乎达到了放热分解反应所需的温度，但工程师和操作员并不知情。反应器内迅速升高的压力使得人孔垫片受损（图1）。人孔处立即喷出浓重的白色蒸汽。30秒后爆破片（图2）爆破，剩余的白色蒸汽从反应器底座附近的4英寸通风管排出。最后一次查看时，反应器的温度为124°F。 图1 直径18英寸的反应器人孔 1.2Facility Evacuation Operators initially considered approaching the reactor manway to attempt to reseal the gasket, but the leak was too large to stop and the venting vapor was moving toward them. With the two reactants and the catalyst fully charged into the reactor, no ability to increase the cooling rate, no emergency dilution system, and no reactor vent scrubber,17 they had no choice but to evacuate the area. All seven personnel safely evacuated the facility as the vapor cloud rapidly expanded and began drifting off site to the north and east. 1.2工厂疏散撤离 起初操作员